Certified trainers keep athletes safe from injury. So why do so few Maine schools have them?

Massabesic's assistant coach Ethan Magill and teammate Robert Woods help junior Owen Roberts off the field last season after he was hurt in a game against Cheverus in Portland. Maine does not require medical coverage in "collision" sports. Staff photo by Ben McCanna

Maine high schools lag behind others in New England and the national average in employing certified athletic trainers, widely considered the best line of defense when it comes to keeping young athletes safe from serious injury.

More than a third of Maine high schools offering varsity sports lack regular coverage by athletic trainers. Only 51 of those 143 public and private schools have full-time athletic trainers, who typically attend after-school practices as well as games.

The problem is most acute in small, rural school districts because of lack of funding or access to qualified medical personnel. Thirty-three schools without an athletic trainer have enrollments of fewer than 150 students.

“The only thing that’s going to motivate the smaller schools, it’s going to be something bad happens,” said Tim Beagan, a certified athletic trainer at Poland Regional High. “It’s going to be a lawsuit. Someone gets hurt because no one’s there. It’s going to happen. Then they’ll find the money.”

But it’s not easy. Since 2016-17, five small schools in northern Maine have lost access to part-time athletic trainers after an Aroostook County health care provider pulled its coverage. Ellsworth High finally won a school-budget battle last spring to fund a part-time athletic trainer – only to discover that a $10,000 stipend isn’t enough to entice a qualified candidate.

Organizations such as the American College of Sports Medicine, American Academy of Pediatrics and the American Medical Association recommend that high schools of all sizes employ athletic trainers – licensed health care professionals who are trained in recognizing sports injuries, including those that may be life-threatening. They play a critical role in injury prevention, treatment and rehabilitation.

Injuries are less frequent at schools with an athletic trainer than at schools without one, according to a study published last year in the journal Injury Epidemiology. Recurring injury rates were up to six times higher at schools lacking athletic trainers, the study showed.

“Having an athletic trainer available on-site at practices and competitions to provide care to student-athletes is the No. 1 thing you can do to keep athletes as safe and healthy as possible,” said Dawn Comstock, a Colorado researcher who has tracked national data on high school sports injuries since 2005.

Nationally, 66 percent of high schools had full-time or part-time athletic trainers in 2017-18. In Maine, 64 percent did, placing it last among the six New England states. In Connecticut, nearly 93 percent of schools reported having an athletic trainer. In rural northern New England, Vermont was at 68 percent and New Hampshire at 66 percent.

The 21 largest Maine high schools without an athletic trainer – Ellsworth topping the list with 463 students – compete in 15 sports on average. Nine of the Maine schools without athletic trainers play football, the sport with the greatest risk of injury, according to Comstock’s research.

“If you cannot afford the services of an athletic trainer, then your school can’t afford to offer football,” she said.

Those nine schools often scramble to find coverage by hiring an athletic trainer for home football games on a per-diem basis or by providing EMT service. All but one (Bucksport) have no medical personnel at practices for football or any other sport.

Comstock’s data show that nearly 40 percent of high school sports injuries occur at practices.

TREND GREW, THEN RECEDED

Biddeford High was the first school in Maine to employ a certified athletic trainer when it hired Richard “Doc” Labonte in 1974. In the early 1990s, athletic trainers were still rare. Over the next 20 years they became commonplace at schools in southern Maine and near Augusta and Bangor. Every school in the Southwestern Maine Activities Association, which includes the largest schools in Cumberland and York counties, has an athletic trainer.

“I would say sports are safer, and the only reason I can attribute to that is that 10 years ago the number of athletic trainers in the state of Maine were half what they are now,” said Paul Berkner, director of the Maine Concussion Management Initiative based at Colby College in Waterville.

But the number of high schools with athletic trainers started to plateau this decade before regressing in the past few years.

Still, Maine has made significant strides to make high school sports safer, including a 2012 state law that requires all schools to establish a concussion protocol. There are now detailed procedures before a concussed athlete can return to the classroom and resume sports activities.

Many other important measures have been initiated by the Maine Principals’ Association, which overees high school sports in the state:

— All coaches in Maine now must complete a coaching eligibility course, a first-aid course and become certified in offering CPR and using a defibrillator.

— Limits have been placed on the amount of time spent practicing in the preseason and, in the case of football, how much full-contact action is allowed.

— Rule changes – including a pitch count in baseball, running time for lopsided football games and mandated eye protection in field hockey – have put safety of the athletes ahead of tradition.

— Games are more frequently postponed because of inclement weather, leading to safer playing conditions and travel.

“There’s so much education now,” said Craig Sickels, the athletic director for Freeport schools. “Back in the day, coaches really didn’t have to have any qualifications other than having played the sport.”

Tony Giordano, the athletic trainer at Thornton Academy, checks out Kennebunk lacrosse player Nate Cripps’ shoulder after he took some hit in the game against Thornton Academy.

But, as Berkner put it, relying on coaches, administrators and even standby EMTs to replace the diagnostic expertise of an athletic trainer is short-sighted.

“Coaches cannot manage medical problems,” he said. “They can’t pay attention to a person who is injured. Their job is to coach. We need athletic trainers in every single high school to provide the medical care to our athletes.”

Chris Rizzo, an associate clinical professor at the University of New England and president of the Maine Athletic Trainers Association, put it more bluntly.

“The bottom line is, it really comes down to liability and if I’m relying on a coach’s first-aid knowledge, there’s a lot of liability there,” Rizzo said. “If a school says it can’t afford an athletic trainer, how about a million-dollar lawsuit? How much is that worth to you?”

RECOMMENDED, NOT REQUIRED

Athletic trainers are important liaisons with other medical care providers, helping to set up appointments, schedule surgeries, and coordinate rehabilitative care. Cam Lantagne, a 2018 graduate of Biddeford High, found that out after he broke his ankle in a football game as a junior.

“I’m not sure what would have happened if (Biddeford’s trainer) hadn’t been there,” Lantagne said. “It helped my mom, too, to know how to handle it every step of the way.”

High school athletic trainers also routinely assist with injuries sustained in non-school activities, providing further benefits to students and parents.

Madison Bolduc, a former soccer player at Portland High, suffered a concussion in an offseason, out-of-state soccer game in 2012. The injury went unrecognized by her club team coaches, and the club did not have a protocol for returning to play. Portland High’s athletic trainer Ryan Lucas oversaw Bolduc’s difficult monthlong recovery.

“Nobody on the club team really checked,” said Bolduc, now a 21-year-old senior at Arizona State. “Nobody really knew any steps I should take or when I should play again. So all the steps I took following the concussion were through Portland High. No one else would have really put any restrictions on my playing.”

On a daily basis, athletic trainers evaluate sprains and strains – the most common injuries in high school sports – and oversee rehab to get athletes back in the action.

“They’re there to help you and better yourself for the game,” said Massabesic junior Owen Roberts, who suffered chronic leg cramping in the team’s season-opening football game last fall. “Personally, they help me a lot.”

No state requires schools to hire athletic trainers. Administrators and athletic trainers said such a mandate would only work if supported by public funding. They recognize that is an unlikely scenario.

“When you mandate something and can’t provide for it, then you’re setting up schools to fail,” said Mike Burnham, assistant executive director at the Maine Principals’ Association and the liaison to the MPA’s Sports Medicine Committee.

“We’re on record that we recommend having athletic trainer coverage, but because of financial implications we can’t require it. Plus, there are parts of this state where those services are just not available.”

Maine does not require medical coverage at “collision” sports, something that is mandated by athletic organizations in Vermont (football, ice hockey, lacrosse, wrestling), Massachusetts (football, varsity ice hockey, rugby, wrestling), and New Hampshire (football only). In Vermont, state law dictates that qualified medical personnel attend high school football games.

The MPA does recommend its schools provide medical coverage at football games and ensures an athletic trainer is present at championship events in all sports.

Maine, like the vast majority of states, does not collect data on high school injuries. But the MPA has supported and promoted the work of the Maine Concussion Management Institute, which currently receives detailed concussion incident reports from about 40 Maine high schools.

‘ONE OF THE HAVE-NOTS’

The factors that keep schools from hiring athletic trainers – lack of money, isolated locations and small enrollments – are becoming more pronounced. Secondary school enrollment has decreased more than 10 percent statewide over the past decade – and is shrinking even faster at the 41 public schools without athletic trainers. Those schools’ cumulative enrollment decreased 29 percent between 2006 and 2018, based on MPA enrollment data.

Athletic directors across the state, like Ellsworth’s Josh Frost, agree with the health care experts. That’s why Frost kept putting in a budget request for an athletic trainer for an athletic department that fields 22 varsity teams, including football and wrestling. After the requests were cut the previous two years, Ellsworth approved a $10,000 budget item for 2018-19 to provide game coverage by an athletic trainer.

Frost has yet to find someone to fill the position on a permanent basis, though he is working with a local company to provide game coverage for the winter season.

Sacopee Valley in Hiram has had money allotted for athletic trainer services for several years, but the modest stipend has not been enough to persuade an athletic trainer to consistently travel to the rural school near the New Hampshire border.

“The job of trainer, in and of itself, is not something a person could make a living off,” said Jim Walsh, the athletic director and assistant principal at Sacopee Valley in Hiram. “Our ideal would be to have a full-time trainer here that could work with our athletes pretty much on a daily basis. We’re unfortunately not in that position. We’re one of the have-nots in terms of not being able to attract a candidate.”

Increasingly, athletic trainers are employed by health care providers and then hired by schools as contracted labor. For larger schools, that can provide significant cost savings with no loss in service. For example, the Biddeford school district saved over $20,000 when it switched from directly hiring its athletic trainer ($47,837 in 2015-16) to contracting with Southern Maine Health Care ($27,000 in 2017-18).

‘IT’S A LOCATION THING’

But a health care provider can pull coverage. That’s what happened in Aroostook County, where over the past two years Ashland, Central Aroostook, Easton, Fort Kent and Wisdom lost the 200-to-300 annual hours of in-school service they had been receiving from County Physical Therapy, based in Presque Isle.

“They cut us because they were going to bump us up about $5,000,” said Eric Werntgen, the athletic director at Fort Kent. “They were pretty upfront. They weren’t making enough money.”

Werntgen still has $4,000 budgeted for athletic services, which he is using to pay his school nurse on a per diem basis.

“It’s a location thing,” Werntgen said. “There’s only so many certified trainers up here. Even if I hired someone for $4,000, they’re not going to come up here for that.”

And so the challenge continues, trying to ensure the safety of high school athletes in far-flung communities often strapped for cash.

“I think everyone would agree that you want a health care professional on the sidelines but in reality, it’s hard. Trying to figure out the funding is the conundrum,” said Ben Towne, a Saco resident and the president of the New Hampshire Athletic Trainers Association.

“Maine and New Hampshire aren’t different from a lot of states. At the end of the day, it comes down to a concerted effort from a group of people to say if we are going to have our students participate in sports, then we have to provide a level of health care.”